Scientific Abstract Presentations: Craniomaxillofacial Session 7 Friday, September 27 Fri, Sep 27 2:00-3:30 p.m. PDT

Purpose: Condylar neck fractures are currently treated with soft diet, maxillomandibular fixation (MMF), or open reduction and internal fixation (ORIF). Literature suggests that operative fixation results in improvements in malocclusion, interincisal opening, jaw deviation, and jaw pain. Operative fixation can be performed via intraoral endoscopic-assisted, preauricular, or retromandibular approaches. Our study aims to simplify the decision-making process in treating of these complex mandible fractures by developing a management algorithm that takes into account patient and fracture characteristics.

Methods: Retrospective review was performed of patients who underwent operative treatment of their condylar neck fractures from 2016-2022 (n=22). At our institution, patients with an isolated fracture with no loss of height were treated with a soft diet. Patients with malocclusion due to a second mandibular fracture but no loss of height of the condylar neck fracture were managed with closed reduction and mandibular maxillomandibular fixation (MMF) during ORIF of the second fracture. Patients with malocclusion and fracture displacement (loss of height) but no dislocation were treated with operative fixation using either a retromandibular (n= 5) or an intraoral endoscopic-assisted approach (n=9). Patients with displacement and dislocation were first treated with a preauricular approach for the dislocation, then with operative fixation via retromandibular or with an intraoral endoscopic-assisted approach (n=8). We analyzed these cases and their respective outcomes to develop our treatment algorithm. Assessment included operative time, occlusion, interincisal opening, jaw deviation, post-operative pain, and post-op complications.

Results: Condylar neck fractures were predominantly observed in males (81%), often combined with other mandible fractures (59%). Patients with condylar dislocation required longer operations (n=8, median time 215 minutes), while those with displacement but no condylar dislocation received a retromandibular operative approach (n=5) and endoscopic-assisted approach (n= 9) with shorter operative times (median 173 minutes and 160 minutes respectively).

Among the 22 patients, 13 underwent adequate follow-up for a minimum of one month. The average duration of follow-up for these patients was 4.3 months, ranging from 1.03 to 24.6 months. Seven patients were lost to follow-up prematurely, (mean 0.44 months, range 0-0.7 months), and two patients had incomplete documentation of outcomes. Among the 13 patients with adequate follow-up, 85% (11 out of 13) successfully achieved restoration of their premorbid occlusion. Additionally, 23% (3 out of 13) with a follow-up average of 1.1 months range: 1.03 to 1.17 months) experienced abnormal interincisal opening post-operation. The same proportion, 23% (3 out of 13), exhibited jaw deviation, while none of the patients reported pain while chewing. Lastly, 15% of these patients (2 out of 13) experienced complications, including ongoing malocclusion and sialocele, neither of which required a secondary procedure.

Conclusions: We present a case series of our algorithm for management of condylar neck fractures. The majority of patients achieved restoration of premorbid occlusion without long-term complications. Using this algorithm has simplified the decision-making process and allowed for effective treatment of challenging mandibular condylar neck fractures.

Purpose: Surgical management of mandibular fractures is among the most common procedures performed by craniofacial surgeons, with established algorithms guiding treatment (Ellis et al., Alyahya et al.). Even with consensus on fracture management protocols, the delivery of equitable care can be susceptible to clinician bias, including consideration of socio-economic status of the patient. The Social Vulnerability Index (SVI) is a well-established percentile value assigned to individuals in geographical areas that can be used as a marker for socioeconomic status, such that more vulnerable populations have higher SVI percentiles. This study aims to explore the relationship between SVI and the selection of surgical repair techniques following mandibular fracture. Methods: Data from Cosmos, a deidentified national database from Epic, was queried for patients with mandible fractures requiring operative fixation by using the five commonest Current Procedural Terminology (CPT) codes for operative mandible fractures as well as the ICD-10 codes detailing fracture characteristics (Ferry et al.). These CPT codes include: open treatment, mandibular fracture with interdental fixation (21462); open treatment, complicated mandibular fracture, multiple surgical approaches including internal fixation, interdental fixation, and/or wiring of dentures/splints (21470); open treatment, mandibular fracture without interdental fixation (21461); open treatment, mandibular condylar fracture (21465); and open treatment, mandibular fracture with external fixation (21454). The identified patients were then stratified into demographic cohorts by SVI quartile. Data were analyzed using a Chi-Square test for trends. Results: This query identified 21,533 patients who underwent operative fixation of mandibular fractures from 2013-2023. Of these patients, 52.2% (n=11,231) underwent open treatment with interdental fixation, 34.4% (n=7,407) underwent open treatment requiring multiple approaches, 20.1% (n=4,324) underwent open treatment without interdental fixation, 5.7% (n=1,226) underwent mandibular condylar fracture repair, and 1.4% (n=299) underwent open treatment with external fixation. Interestingly, patients with higher SVI were more likely to have an ICD-10 diagnosis of closed mandibular fracture (p<0.0001). However, patients with lower SVI were more likely to have an ICD-10 diagnosis of condylar fracture (p<0.0001). Analysis for SVI percentile identified significant trends for two surgical techniques. Patients with a higher SVI were more likely to undergo open treatment of mandibular fracture without interdental fixation (CPT 21461, p=0.0058). Conversely, patients with a lower SVI were more likely to undergo open repair of mandibular condylar fracture (CPT 21465, p=0.0066). Conclusion: These results suggest that there is an association between SVI and mandible fracture repair technique. Patient factors, such as severity and type of injury in addition to dental status and occlusion, may differ between SVI groups. For example, poor dentition in a higher SVI group may preclude the choice of interdental fixation. In contrast, patients with better dentition with a lower SVI group may experience symptomatic malocclusion with condylar fractures, thus resulting in more open treatments for this group (Weiss et al.). Further investigation is necessary to understand the patient and provider factors that are responsible for these findings.

References 1. Ellis E. An Algorithm for the Treatment of Noncondylar Mandibular Fractures. Journal of Oral and Maxillofacial Surgery. 2014;72(5):939-949. doi:10.1016/j.joms.2013.11.026 2. Alyahya A, Ahmed AB, Nusair Y, Ababtain R, Alhussain A, Alshafei A. Mandibular condylar fracture: a systematic review of systematic reviews and a proposed algorithm for management. British Journal of Oral and Maxillofacial Surgery. 2020;58(6):625-631. doi:10.1016/j.bjoms.2020.03.014 3. Ferry AM, Beh HZ, Reul RMJ, et al. Limitations of Coding and Reimbursement Systems for Surgical Correction of Mandibular Fractures: What Are They and How Can Craniofacial Surgeons Fix Them? Plastic and Reconstructive Surgery. 2022;149(2):357e. doi:10.1097/PRS.0000000000008734 4. Weiss JP, Sawhney R. Update on mandibular condylar fracture management. Curr Opin Otolaryngol Head Neck Surg. 2016;24(4):273-278. doi:10.1097/MOO.0000000000000272

Background:

Cranial vault remodeling (CVR) for the treatment of craniosynostosis has been associated with substantial blood loss with a high incidence of allogenic blood transfusion. Transfusions have been associated with risks including metabolic acidosis, bacterial or viral contamination, fluid overload, lung injury and other transfusion-related reactions. The purpose of this study was to identify modifiable factors that may predict post-operative transfusion in order to reduce the rate of allogenic blood transfusion in patients undergoing CVR.

Methods: A retrospective review of the electronic medical record was conducted to include patients who underwent cranial vault remodeling between 2012 and 2020 at the Children's Hospital of Wisconsin. Demographic and intraoperative variables were tabulated. Outcomes of interested included postoperative transfusion.

Results: This study included 237 patients with craniosynostosis. The most common diagnosis was sagittal synostosis 48%. Intraoperatively, 41 (17.3%) of patients received tranexamic acid (TXA). 115 patients (48.5%) required a transfusion of blood products postoperatively. Intraoperatively, patients received 49.0 ± 37.6 cc/kg of blood products on average. Children that received TXA were less likely to receive a postoperative transfusion (p < 0.001). Children that received a drain were more likely to receive a postoperative transfusion than those children who did not receive a drain (p = 0.004) and children who received NSAIDs were less likely to have a postoperative transfusion than children that did not receive NSAIDs (p < 0.001). There was a significantly higher intraoperative crystalloid volume administered in the group that received postoperative transfusion (M = 50.3 cc/kg, SD = 32.2) than those children who did not receive a postoperative transfusion (M = 39.7 cc/kg, SD = 21.3), (t (235) = -3, p = 0.002). Total operative time and total intraoperative blood products transfused (cc/kg) had a weak but significant positive relationship (r = 0.22, p = 0.001).

Conclusions: TXA administration was associated with reduced transfusion requirements. NSAID administration postoperatively did not confer more postoperative transfusions.
While we found that the use of drains, increased intraoperative fluids, and operative time correlated with postoperative transfusions, these factors may reflect a more extensive operation.

Background  To restore a regular contour following cranioplasty, often an extradural dead space is created between the reconstruction and dura. It is often assumed the brain will ultimately expand and fill this space. However, in delayed or scarred cases, this dead space does not fill and may increase the risk for subsequent seroma or post-operative infection (1,2). The management of extradural dead space has yet to be standardized or summarized in the literature.

Methods  A systematic review of the literature was performed via searches of Embase, Cochrane, and PubMed in accordance with PRISMA guidelines. All English-language studies published before February 10, 2024 that described the risks or management of extradural dead space during cranioplasty were included. 

Results  Of 544 screened articles, 65 underwent full-text review and 26 were included in the final analysis. All but three articles (n=23, 88%) discussed dead space treatment. The remaining two articles examined whether extradural dead space was a risk factor for mesh exposure (no association was found), seroma formation (dead space was a predictor for epidural fluid collection), or bone flap resorption (greater dead space was found to be a risk factor for resorption). Sixteen studies (62%) discussed filling the dead space with an omental or muscle free flap. Muscle free flaps were often used in the setting of revision cranioplasty after infection. Two papers (8%) discussed a variation of this approach using a combination of a muscle free flap and vascularized rib transfers. Two studies (8%) described filling the dead space with hydroxyapatite. Two studies (8%) described suturing the dura to the bone flap or artificial bone directly, rather than filling the dead space with another material. Only one study (4%) did nothing to obliterate the dead space, instead choosing to wall the dead space off from the paranasal sinuses only. Complications related to filling of the dead space included flap failure (n=1, 4%), and infection (n=3, 12%)  

Conclusions  Management options of extradural dead space during cranioplasty are infrequently discussed. Free flaps are an emerging technique that may reduce the risk of post-operative complications in carefully selected patients. Further research is required to quantify the risks associated with leaving dead space after cranioplasty and determine the safety and long-term patient outcomes associated with using free flaps to obliterate dead space.

References  1) Kumar, A. R., Tantawi, D., Armonda, R., & Valerio, I. (2012). Advanced cranial reconstruction using intracranial free flaps and cranial bone grafts: an algorithmic approach developed from the modern battlefield. Plastic and reconstructive surgery, 130(5), 1101-1109. 2) Lee, J. W., Kim, J. H., Kang, H. I., Moon, B. G., Lee, S. J., & Kim, J. S. (2011). Epidural fluid collection after cranioplasty: fate and predictive factors. Journal of Korean Neurosurgical Society, 50(3), 231.

Introduction/Purpose: Children with craniosynostosis (CS) undergo surgical intervention to mitigate the risk of increased intracranial pressure (IIP) secondary to their volumetric constraints and to normalize cranial head shape. Although metopic craniosynostosis (MC) is not usually associated with IIP, patients with severe dysmorphology improve the normalization of their cranial shape and aesthetics with operative intervention. There is currently no universally accepted metric to assess post-surgical outcomes or aesthetic appearance of patients with unoperated MC [1, 2, 3]. We used our recent quantitative method to objectively evaluate the aesthetic outcomes of groups of patients with both unoperated and operated MC using 3D photogrammetry.

Method: Patients with CT-confirmed diagnoses of MC from 2013-2023 were retrospectively identified at a single institution. A normative model of local head development built from the CT images of 2,020 subjects was used to create a Head Shape Anomaly (HSA) index as previously described indicating the number of standard deviations away from normative distributions the head shape of a patient is, accounting for age and sex [4]. Using 3D photogrammetry, we evaluated patients who underwent open repair of MC pre-operatively and post-operatively and those with MC who did not undergo surgical correction.

Results: Forty-three unique patients who underwent open surgical correction for MC were evaluated both preoperatively (age at photogram: 8.21 ± 4.71 months, 1.61 ± 2.16 months before surgery) and one year after surgery (time after surgery 13.34 ± 11.74 months). Patients who did not undergo surgical repair for MC were evaluated at one year of age. The HSA index of patients who underwent surgical correction (age at photogram 24.06 ± 12.30 months) and five patients with unoperated MC (age at photogram 19.96 ± 16.64 months) were compared. There was a significant improvement in HSA index in MC patients who underwent corrective surgery at one year after surgery (1.619 ± 0.65 before surgery vs. 1.37 ± 0.39 after surgery, p=0.03). Patients with unoperated MC presented a HSA index of 1.98 ± 0.82, which was not significantly different from either the pre-operative (p=0.26) or the post-operative (p=0.09) surgical groups. Of the 5 patients with unoperated MC, 3 patients had mild presentations and 2 patients were offered surgical intervention and elected conservative management.

Conclusion Patients with MC who undergo surgical correction demonstrate an improvement of aesthetic head shape at 1 year from surgical intervention. Interestingly, no differences in HSA index between the pre-and post-surgical group and the unoperated group were identified, which may be limited by the sample size of unoperated patients and the mild clinical presentations of some unoperated patients. It is important to consider that patients with unoperated MC have a wide variety of presentations and do not present a significant trend of increasing HSA index over time.

References: 1. Farber SJ, Nguyen DC, Skolnick GB, Naidoo SD, Smyth MD, Patel KB. Anthropometric Outcome Measures in Patients With Metopic Craniosynostosis. J Craniofac Surg. 2017;28(3):713-716. 2. Leclair NK, Chern J, Ahn ES, et al. Clinical metrics and tools for provider assessment and tracking of trigonocephaly. J Neurosurg Pediatr. 2023;32(1):82-90. Published 2023 Apr 7. 3. Anolik RA, Allori AC, Pourtaheri N, Rogers GF, Marcus JR. Objective Assessment of the Interfrontal Angle for Severity Grading and Operative Decision-Making in Metopic Synostosis. Plast Reconstr Surg. 2016;137(5):1548-1555. doi:10.1097/PRS.0000000000002052 4. Elkhill C, Liu J, Linguraru MG, et al. Geometric learning and statistical modeling for surgical outcomes evaluation in craniosynostosis using 3D photogrammetry. Comput Methods Programs Biomed. 2023;240:107689.

Background: Most craniotomy wounds can be closed primarily. In some percentage of cases, as is common in complex head and neck trauma, significant wounds require more advanced reconstruction techniques. Identifying patients undergoing a craniotomy for traumatic brain injury who are more likely to require a reconstruction for wound closure can help plastic and neurological surgeons plan and allocate resources effectively. This study aims to characterize the clinical differences between patients undergoing craniotomy who need reconstruction compared to those who do not, as well as the inpatient differences in outcomes between the two groups.

Methods: The National Trauma Data Bank was queried from 2017 to 2021 for adult patients with traumatic brain injuries requiring a craniotomy. Patients were divided into the "with reconstruction" and "without reconstruction" groups depending on if they had an accompanying reconstruction of the head and neck region to their craniotomy. The "with reconstruction" group was propensity score matched with the "without reconstruction" group based on demographics, comorbidities, and injury severity. Student t-tests and Pearson χ2 tests were used to assess group differences.

Results: A total of 28889 patients meeting the inclusion and exclusion criteria were identified, of whom 3860 had a concomitant reconstruction and 24525 did not. Patients with reconstruction were more likely to be smokers, on Medicaid, and have a higher GCS score. Following propensity matching, there 3860 patients in each group. Patients with reconstruction had a higher length of stay in the hospital (21.6 vs. 16.6 days, p<0.01), were more likely to develop pressure ulcers (5.1% vs. 3.0%, p<0.01) and deep venous thrombosis (6.0% vs. 4.8%, p<0.02), and more likely required discharge to a long-term facility (8.1% vs. 6.5%, p<0.01). The mortality rate did not differ, however, between the patient groups.

Conclusions: Patients undergoing craniotomy with accompanying head and neck reconstruction demonstrate a clinical profile that suggests a more severe brain injury and additional risk factors that can complicate their wound closure. They also experience a longer length of stay and complications consistent with prolonged hospitalization. Plastic surgeons would benefit from working with neurosurgeons to identify which patients will require reconstruction and be more aggressive with prophylactic measures against complications of prolonged hospital stay.

Background: Septorhinoplasty is one of the most common surgical procedures performed by plastic surgeons. Although sparsely reported, iatrogenic injury to the delicate cribriform plate during septorhinoplasty due to middle turbinate resection or manipulation can result in severe complications such as CSF leak and meningitis. (1) The intimate and complex relationship of the anterior cranial skull with the middle turbinate, perpendicular plate of the ethmoid (PPE), and nasal bones is often under-recognized, and rarely studied among plastic surgeons. Through a CT-guided analysis, this study established a clear anatomic relationship between the middle turbinate, PPE and cribriform plate to provide the plastic surgeon with a roadmap for staying safe during septorhinoplasty.

Methods: A retrospective chart review of patients ≥ 17 years of age who underwent CT sinus imaging was conducted. Patients receiving sinus CT scans due to traumatic etiologies, syndromic patients with abnormal nasal anatomy, and patients with a history of prior septorhinoplasty or sinus surgery were excluded from the study. 150 CT scans were randomized for evaluation and analyzed for the following measurements: 1) length of the cribriform plate, 2) length of the middle turbinate, 3) distance of middle turbinate anterior attachment from the origin of the cribriform plate, 4) length from basal lamella of the middle turbinate to sphenoid sinus, nasal bone length, and angle of anterior nasal spine to cribriform plate.

Results: The mean age of patients with scans was 46.83 ± 24.02 years, with 58% female and 42% male. The length measured from the crista galli to the anterior sphenoid sinus averaged 29.50 ± 4.17 mm. The length of the middle turbinate extended more posterior than the cribriform plate in all patients and averaged 38.38 ± 4.45 mm. All patients had middle turbinate attachments to the cribriform plate, with an anterior attachment of 5.79 ± 1.89 mm, which was 17 ± 6% of the total length of the cribriform plate. The length measured from the basal lamella to anterior sphenoid sinus averaged 12.48 ± 2.46 mm, which was 43 ± 10% of the length of the cribriform plate. The length of the nasal bone was 21.04 ± 3.80 mm and the distance from the anterior nasal bone to the cribriform plate was 30.35 ± 4.50 mm. The angle measured between the anterior nasal spine and cribriform plate was 67.12 ± 3.54°. These measurements demonstrated that a significant portion of the middle turbinate arises from the cribriform plate.

Conclusions: This study clearly defined the anatomic dimensions of the structures adjacent to the cribriform plate using CT-guided measurements. While medical illustrations commonly depict middle turbinate attachment to the lateral nasal wall, our study demonstrated the direct connection of the middle turbinate to the cribriform plate. Anatomic knowledge of these structures may guide the plastic surgeon to avoid unfavorable fracture patterns and anterior skull base injury during middle turbinate manipulation during septorhinoplasty.

References: 1.Youssef A, Ahmed S, Ibrahim AA, Daniel M, Abdelfattah HM, Morsi H. Traumatic cerebrospinal fluid leakage following septorhinoplasty. Arch Plast Surg. 2018;45(4):379-383. doi:10.5999/aps.2017.00913

Background
Pediatric corrective nasal septal surgery is a controversial procedure, as the rapid growth spurt that adolescents experience can alter the anatomy of the midfacial region. However, surgery is often the best course of treatment in the case of facial trauma or severe nasal obstruction. It is suggested that the rate of revision surgery is higher in children than in adults due to the midfacial anatomical changes that adolescents experience; however, we lack sufficient evidence regarding the complication and revision rates of pediatric primary nasal septal surgery. Our study aims to understand the current clinical guidelines and safety profile of performing pediatric septorhinoplasty with an emphasis on understanding the optimal age for this procedure.

Methods A systematic review of PubMed, MEDLINE, and CINAHL was conducted using PRISMA guidelines. Clinical studies from 1994-2004 involving primary nasal septal surgery in children aged 0-18 years were included. Articles were excluded if study data involved subjects aged 19 years or older. Case series and cohort studies were included, and case reports were excluded. Two independent reviewers screened full-text articles to apply inclusion and exclusion criteria. Three reviewers each conducted data extraction of all studies, which was done independently to control for bias. Data was collected on patient-reported outcomes, postoperative complications, and rates of revision surgery. Descriptive analyses were performed using R Software.

Results There were 31,875 patients from 27 studies that met inclusion criteria. The mean age at primary surgery was 12.4 ± 1.2 years. With respect to specific types of procedure, septoplasty was performed in 63% of all articles, rhinoplasty in 25.9% of articles, and septorhinoplasty in 22.2% of articles. The average rate of complication across all studies was 9.9% ± 4.1%. The average time to complication was 34.0 ± 5.1 days. The average rate of revision was 4.2% ± 10.3%, and revision was most frequently indicated for recurrent nasal passage obstruction (58.9%). The mean time to revision septoplasty was 775.1 ± 314.0 days, and the mean age of participants at revision surgery was 17.8 ± 3.4 years.

Conclusion Pediatric corrective nasal septal surgery demonstrates generally low complication and revision rates. Complications were minimal and largely occurred during the peri-operative period, suggesting that midfacial anatomical changes that are distributed over a longer time period do not affect the timing of complications. Revision surgery, when indicated, occurs approximately two years following the primary procedure and typically at the late adolescence stage; however, additional data is needed to understand the optimal timing of revision surgery, as this was reported in only 18.5% of studies. Overall, our findings indicate that performing septorhinoplasty in the pre-adolescent years is generally safe. Long-term follow-up studies can help determine an optimal age range for which the postoperative complication rate and revision rate are minimal.

Background: Mandibular fractures are a common consequence of several mechanisms of injury including assault, motor vehicle accidents, and falls. Facial traumas that lead to mandible fractures are typically either blunt or penetrating. Previous studies have examined the pattern of craniofacial fractures created by different mechanisms of injury; however, little research has examined overall fracture patterns across all sites of the mandible and the effects of blunt and penetrating trauma on these patterns. Purpose: To review the fracture patterns including secondary fracture sites for both blunt and penetrating trauma to the mandible over a 10-year period at a single institution. Methods: A retrospective chart review was performed on all patients who were treated at Saint Louis University for mandible fractures from January 2013 to December 2022. Variables collected for analysis included mechanism and date of injury, fracture location(s) within the mandible, comminution, and demographic data (i.e., age, gender, and race). Chi-square analysis was performed for categorical variables and student's t-test was performed for comparison of means of continuous variables. Results: 570 patients with mandible fractures were identified in the 10-year time span. Motor vehicle accidents were the most common cause of these injuries, accounting for fractures in 203 patients (35.6%). The most common location of mandibular fractures was the body, which was fractured in 30.3% of patients. This was followed by the parasymphysis (26.0%), angle (23.9%), ramus (17.4%), subcondylar region (13.3%), condyle (12.4%), symphysis (6.6%), and coronoid process (6.5%). Blunt trauma caused significantly more subcondylar and condylar fractures as well as parasymphyseal fractures compared to penetrating trauma (p<0.05). Patients who had penetrating trauma caused a significantly higher proportion of body fractures (p<0.05). The most common fracture patterns were isolated body fractures, isolated angle fractures, and angle/parasymphysis fractures. When broken down by grouped fracture patterns, a significant difference in distribution was seen between blunt and penetrating trauma. Blunt trauma cases were more likely to present with multiple fractures and with fractures of the posterior mandible, including the condylar and subcondylar regions. Comparatively, penetrating trauma was associated with higher rates of singular fractures and with fracture sites in the anterior mandible. The difference in parasymphyseal fracture rates seen on individual fracture site analysis was shown to be largely due to blunt trauma causing a significantly larger number of angle/parasymphyseal fracture patterns. Conclusion: Mandibular fracture sites are well studied. Most previous literature focuses on rates of injury at individual sites on the mandible. This study demonstrates that it is useful to think of mandibular fractures in terms of the pattern of their placement across all sites on the mandible rather than as isolated, individual areas of injury. The mechanism of injury to the mandible partially determines the fracture pattern observed. The differences in the transmission of force during blunt and penetrating trauma result in measurably dissimilar fracture patterns generated within the mandible.

Introduction: Idiopathic intracranial hypertension (IIH) is defined as elevated intracranial pressure (ICP) without a clear etiology. In refractory cases with imminent visual deterioration, surgical management, including cerebrospinal fluid shunting or optic nerve sheath fenestration, is offered as a last resort. This study examines our use of posterior vault distraction osteogenesis (PVDO) as a novel surgical treatment for pediatric patients with refractory IIH and evaluates the relationship between skull suture fusion and elevated ICP in this population. Methods: A retrospective review was conducted on pediatric patients diagnosed with IIH and age- and sex-matched controls who had undergone head computerized tomography (CT) scans. In addition to general demographics, data collected included clinical findings on presentation, previous noninvasive treatments for IIH, and perioperative details about PVDO. Patients were excluded if they had a history of other inherited or acquired craniofacial conditions or had undergone craniofacial or neurosurgical procedures other than PVDO. Utilizing the head CT scans, a 5-point scale developed by Madeline and Elster was employed to grade major and minor cranial suture fusion. Results: Fifteen patients with IIH and thirty-one controls were included in this study. Compared to unaffected controls, patients in the IIH group had a higher BMI (32.9 vs. 22.0, P = 0.01). Within the IIH group, patients undergoing PVDO (N = 3) were significantly younger at the time of diagnosis (6.7 vs. 13.1 years of age, P = 0.004). Three patients underwent PVDO with significant improvement in their symptoms. The average latency phase, active phase, consolidation phase, time from distractor placement to removal, and distraction distance were 1.3 days (1-2 days), 29.3 days (23-40 days), 167.5 days (146-189 days), 230 days (189-287 days), and 25 mm (23-29 mm), respectively. Although one surgical patient had a fused sagittal suture, we found no clinically significant association between IIH and premature suture fusion. Conclusions: PVDO appears to be a safe and effective treatment for managing pediatric patients with refractory IIH. Although one patient had premature fusion of the sagittal suture in our study population, there was no association between craniosynostosis and IIH.

Purpose For patients with severe facial trauma or disfigurement, facial transplantation has the potential for providing significant reconstructive restoration. Depending on the patient's individual circumstances, face transplantation may include bone as part of the donor allograft. However, the long-term integrity and composition of these donor bone grafts remains uncertain. Thus, the purpose of this study is to provide a long-term quantification of bone volume changes within a single institution cohort of face transplant patients.

Methods Individual maxillofacial/head CT scans for eight patients (six male, two female) were identified from 2011-2023 across two time points: about one year post- face transplantation and the most recent scan available for each patient. CT scans from each timepoint were analyzed in Materialise Mimics (v25) software to segment out the bony anatomy from each scan and calculate the volume of the mandibular and maxillary components. Volumes were compared of each anatomical component utilizing Wilcoxon Signed-Rank Test.

Results Out of eight face transplantation patients, three had a combined maxilla and mandible bony allograft included in their face transplant, one had a maxilla-only bony allograft included, and four had only soft tissue allografts with no bone included. On average, patients were 10.1 years post-transplantation (range 5-13 years) and had an average duration between scan timepoints of 6.5 years (range 1-12 years). Across all patients, there was a significant median decrease in both mandibular (-5,131 mm³; p=0.0078) and maxillary (-2,740 mm³; p=0.0078) volumes over time. When specifically comparing the volume changes between the cohorts who received bony allografts versus those that did not, patients with bony allografts had an average change of -4,242 mm³ for their mandible and -3,219 mm³ for their maxilla over time, in comparison to an average volume change of -8,519 mm³ for the mandible and -3,492 mm³ for the maxilla observed in patients with non-bony allografts.

Conclusion This study provides the first quantification of facial bone volume changes in face transplant recipients over an extended multi-year follow-up period. Although the results show significant volume loss in the mandible and maxilla of face transplant patients over time, the average volume loss in the soft tissue only allograft patient cohort was greater than that seen with the bony allograft cohort in both the mandible and maxilla. Although preliminary, this finding suggests that patients with bony facial allografts may not experience any accelerated degeneration. The etiology of the overall volume decrease is likely multifactorial with impacts from the natural degenerative processes that occur with aging, loss of teeth, the influence of life-long immunosuppressive therapy and episodes of rejection, and allograft interactions with the recipient's immune system.

Background: Because the metopic suture fuses normally in infancy, the determination of pathological metopic fusion rests on the degree of forehead narrowing. Current diagnostic techniques for metopic craniosynostosis rely on subjective criteria, 2-dimensional measurements, or 3- dimensional analysis that fail to capture individual variation of shape. This study presents an objective, data-driven normative model that represents the age- and sex-specific variability of forehead deformation.

Methods: A retrospective review of computed tomography (CT) scans of patients aged 0 to 24 months who presented to the emergency department between 2010 and 2023 was completed. Patients with craniosynostosis (CS) or associated syndromes, history of hydrocephalus, or other brain/cranial abnormalities were excluded. Each patient underwent cranial shape analysis. Optimal interfrontal angle (oIFA), transverse forehead width (TFW), skull circumference (SC), intracranial volume (ICV), and malformation range (MR) were calculated. Differences between groups in relation to age, gender, and race were measured by multinomial regression.

Results: Cranial shape metrics were calculated for 645 patients, with a minimum of 25 patients in each month group. The patients' median age at the CT scan was 11.0 months; slightly over half of the patients (55%) were male and (58.9%) African American. The median oIFA was 141.2°, TFW was 56.6 mm, SC measured 415.4 mm, and ICV was 988.0 cm³. MR was assessed for specific skull bones, revealing variations within normal limits. Our analysis found that males demonstrated a significantly higher mean ICV compared to females (1036.5 cm³ [846.7, 1176.8] vs. 944.2 cm³ [771.6, 1061.1], with p < 0.001).

Interestingly, a sub-analysis categorizing the patients by age group found a trend where oIFA distribution and TFW distribution were inversely proportional. Specifically, oIFA showed a slight decrease with increasing age, moving from 138.9 ± 19.3° to 137.3 ± 19.0°, while TFW showed a slight increase from 55.8 ± 23.9 mm to 62.1 ± 25.9 mm. Moreover, we found a very strong and statistically significant correlation between age and ICV (Pearson's r=.75; p <0.001), indicating that, on average, the ICV tends to increase by about 198 mm for every one-unit increase in log age (in months) in males, and 129 mm in females.

Conclusion: The determined metrics provide an objective normative forehead angulation in a cohort of 645 patients, representing the largest and most comprehensive study to date. The evaluated metrics establish a standardized framework for objectively evaluating craniofacial morphology and removing subjectivity in determining pathological forehead narrowing from normal variation. The presented approach advances the precision of diagnosing trigonocephaly, and the observed inverse relationship between oIFA and age, coupled with age-related increases in TFW and ICV, provides valuable insights for guiding surgical interventions in metopic craniosynostosis.

Introduction Cranioplasties are crucial for ensuring cerebral protection, restoring neurological function, and improving psychosocial well-being. However, current available cranioplasty materials have significant drawbacks; autologous bone grafting is constrained by limited availability and donor site morbidity, while alloplastic materials are associated with high complication rates. Consequently, there is a clinical need for regenerative bone biomaterials that emulate properties of tissue-specific extracellular matrix (ECM) and regulate progenitor cell fate. Nanoparticulate mineralized collagen glycosaminoglycan (MC-GAG) promotes in vitro osteogenic differentiation and in vivo skull regeneration without exogenous growth factors and ex-vivo progenitor cell seeding, offering a promosing "materials-only" solution for osseous defect reconstructions. Further refinement of the material is however imperative to enhance safety and regenerative potential for clinical translation. A pertinent challenge faced during early bone healing is ensuring the protection of underlying structures while simultaneously maintaining optimal intracranial pressure to support neurological function. In this work, we investigated how the regenerative capacity of MC-GAG may be influenced by its fixation and overlay with a clinically available resorbable poly(D,L-lactide) (PDLLA) implant intended for cerebral protection.

Methods A 14-mm full thickness, extradural defect was created in each New Zealand white rabbit. Animals were divided into 4 groups: 1) defect without reconstruction, 2) defect with PDLLA implant, 3) MC-GAG scaffold only, and 4) MC-GAG with PDLLA implant. Initial bone healing assessment was conducted on explanted skulls at 3 months using microcomputed tomography (microCT) scanning, histology, and reference point indentation. For a comprehensive understanding of long-term effects, in vivo microCT imaging was subsequently performed at 3, 6, and 9 months, with further examination biomechanical properties of explanted skulls at 9 months.

Results At 3 months, the explanted skulls revealed that MC-GAG significantly enhanced mineralization in comparison to the empty and PDLLA-treated defects, with even greater mineralization observed for the MC-GAG-PDLLA combination scaffold. Histological analysis of the interface between the reconstruction and native bone indicated that MC-GAG promoted the development of an intricate network of trabecular mineralized content whereas the untreated defect primarily featured fibrous, non-mineralized tissue. MC-GAG-PDLLA demonstrated enhanced structural organization more closely representative of nearby native bone. Biomechanical assessment of the treated skulls demonstrated enhanced toughness and resistance to microfracture of both MC-GAG alone and MC-GAG-PDLLA compared to the empty and PDLLA-treated defects, with significantly greater measures of stiffness for MC-GAG-PDLLA. While no difference in regenerated bone mass was detected by in vivo CT between the treatment groups after 3 months, MC-GAG-PDLLA exhibited the highest bone mass at 6 months, and both MC-GAG-containing scaffolds demonstrated enhanced bone regeneration compared to the empty and PDLLA-treated defects at 9 months. By 9 months, PDLLA implants were completely resorbed, and analyses of the mechanical properties of explanted skulls at 9 months revealed that both strength and stiffness were greatest and most similar to native bone for MC-GAG-PDLLA.

Conclusions Together, these results demonstrate that the reconstruction of a cranial defect with a MC-GAG scaffold fixated with PDLLA implants significantly enhanced long-term mineralization and bone regeneration compared to a scaffold consisting of either MC-GAG or PDLLA alone.

Purpose: Orthognathic surgery significantly improves quality of life by addressing dentofacial deformities and enhancing dental occlusion, temporomandibular joint function, and facial aesthetics. This study introduces the Early Postoperative Recovery Score (EPRS) to evaluate early post-surgical recovery, addressing the gap in understanding how preoperative characteristics influence postoperative outcomes, including hypernasal speech, dysphagia, and obstructive sleep apnea (OSA).

Methods: We retrospectively reviewed charts of patients who underwent orthognathic surgery from 2015 to 2022, collecting data on demographics, clinical characteristics, and postoperative outcomes to construct the EPRS. This metric aggregates postoperative factors like hypernasal speech, dysphagia, respiratory issues, OSA, surgical site infections, and other complications into a quantifiable recovery measure. Logistic regression analyses were conducted to evaluate the effects of preoperatively measured age and BMI on overall recovery, including the incidence of postoperative obstructive sleep apnea (OSA). The EPRS served as a dependent variable in logistic regression models, categorizing patient recoveries into more stable (score >1) and less stable (score ≤1) groups. Each postoperative complication, such as surgical site infection, speech difficulties (e.g., hyponasality or hypernasality), swallowing difficulties, and persistent OSA, is assigned a point. The score is incremented to reflect the complexity of recovery associated with each complication.

Results: Among 88 patients, 53% were male, and 65% were White/Caucasian. Most (84.1%) had a preoperative BMI under 35 kg/m², with 35% reporting cleft palate histories. We observed surgical site infections in 18.4%, primarily in the mandible (12.6%). A higher preoperative BMI (≥ 35 kg/m²) significantly correlated with persistent post-operative OSA (OR: 2.091, 95% CI: 1.326-3.578, p = 0.007). Similarly, older age increased the risk of OSA post-surgery (OR: 1.147, 95% CI: 1.042-1.263, p = 0.005). Multivariable analysis demonstrated that patients with a cleft palate were significantly more likely to experience specific postoperative recovery issues, as quantified by the EPRS, with an odds ratio of 1.344 (95% CI: 1.003-1.901, p = 0.048). Surgical details showed that 78.4% had combined maxillary and mandibular osteotomies, 95.5% underwent Le Fort 1 osteotomy, and 85.2% had BSSO. Maxillary advancement occurred in 62.5% of cases (average advancement: 5.179 ± 6.278 mm), and 4.3% had inferior vertical lengthening. In the mandible, 10.2% had advancement, and 17.1% underwent a setback, with the procedure length averaging 541 minutes.

Conclusion: The EPRS provides a structured approach to quantifying early recovery after orthognathic surgery, with preoperative BMI, age, and cleft palate history emerging as significant outcome predictors. This metric offers insights into postoperative recovery, potentially guiding future patient management. Further validation of EPRS could refine its clinical application, enhancing outcome prediction and patient care strategies in orthognathic surgery.